GW1-2022-01329_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD Fw lwtertgO Use ONt Y:
'Ibis form can be nxd for single or mollipk wetls
i.Wdl Contractor information:
i1>'t,V 12 7,0
Robert Miller FR M PtYnO`i
A14:11Contnset"Nanle
fG R,
2675
NC WeR ContmctorCcniftwtion Nar bff 1.0U 1pit CASi`%409r"011-a>rhe vvl h t3RUNIM' `s re`
FROM To PTAMFM TRtCF:WWS MATERIAL
SASDACCO Inc 0 fL 103 fL 6" is SCE-40 PVC
(teaooy Naft .40 g it.z�aaba Ajtlosed-loo
FROM TO ntA.niETM Tlr(CAhTM L MATWRiAL
2.Well Construction Permit#: 0 ft. 109 R. 2" hi: SCH-40 PVc
LW all eWirwNe well pennia(i e.Caunh.Swk-,Variancr,If ferdat err.) h h+ hL
3.Wdt iJsc(chedt wdl pse}: 17: <KItt R
Water Supply Well: FROM TO PtAMItIr:R I WS I MAT tot
OA$licitlttiml 1 municipal/ftlic 109 ft. 124 R 2" is .010 SCH-40 PVC
OGwthcntml(HeatirVCooling Supphy) OResidential Water Stfpply(single) ft. R. I&
tP liR0}T®Eodswl/Conmteldai OResidential Water Supl y(shaed) FROM To MATEPUL fFtAC£. T=MLr GV AMO1hPi
01ni Lion 0 (L 103 (L Port land/Be'niobibe
Non-Water Sttpply♦Yell: 0 ft. 102 FL Portland/ B bnite
®Monttorin ORccot
in on Well: fL (L
QA�quiferRCCk1 ge oGmundtraterReniediation t . .
FROM r TRIK KMPrA P1TVt1 TMr:Ttl n
OAquikr Storage and R=*,v q OS,�linit Barrier 107 It. 124 f1 Silica Sand 20/30
OAquifer Tcst osto"n"ter Dmin.7ve ft. ft.
oExperimotal Tcchnologr ost"dcucc Con"I
'1tt ARi1�1di•t3 wG wttlCtl,atiditlonil:sbt�sif,
oCkothennal(Closed Imp) t3Tmcer L�-
CherokeeTO oF-SMtMON out.bled"tti3,enWftk Waek.1
oGeothennal(Reatin oohs Return) 00ther iain ultder 021 Rematks 60 n. Tan Silty sand
124 (1. weathered rock
4.Date Well(s)Completed: 12-9-21 WdiM#DMif-2 R
50.Well taeaftrin:NC DOT (L 6aV i..Faer0hy)0w>;=Name Faculty IDR(ifuPplieablki5426 NC-141 Marble, NC, 28905 (L
FiOsical Address.City-.and Zip fiv foot bentonite seal from 102' to 107'
f anwtly trartef Wmfrcalioa)na.(PIN)
Sh.Latitude and Longitude in degnxsimimtties/seconds or decirnal degrees. 2L Certification:
(if rtrl tigld,m1a 4ttAoM is swdl)r4erwt) ..'
N
12/16/2021 W Dace
6.is(are)the welt(W. oPermaneut Or oTemporar} srgafaig rhtx foam /hrreb}arrtifi rhrit rhr ntlbjs7 uvs(►sere)[rinfrnrtrtd drt atiardrinrr
%lrh!M NCAC 02C.01-r or)M NCAC(t2C,0200 iVeli Cojutmwdon Smndmdr and Arise o
7.Lc this a repair to an existing well: oVo or MN1r MffOf dwir rrconl ho,bemn pm-mm era thcur.Atraearr,
t1AU h a rrprdr.fill lwt.bowin uvU cownft fem Womw don and rWfofa rho awrore of d1e
-Mir wrder 021 temurks an9iasa or on dwr brwk of rhrs form. 23.Site diagram or additional Srelldetalk-
You may use the back-of this page to ptocide additional rirll site details or well
8.Number of wells constructed: 1 Constluctian details. You may also onach additional pages if necessary.
For mutdplr 1"*rlmi or mm-uwwt,sWply wrfls ONLY n1rh dw wme consewilm.you rmi }jhtj97 dL B!'S C1C T701VC
subadr 0"form
9.Total welt depth below land surface 124 {n,) 24s. Far All Wells: Submit this form biotin 30 days of eompWon of twit
Forowhiale wants hirofiderAr 1(dill'rmij fexmraple-3Q2M'oW 2@'1aTj connun ction to the following:
10.Statle water lMVl below top of easing: {(1,) Division of Water Rcsoutre.information Pmtryessing Unit.
/f%Vmo,aryl if abo:-r crtltlug,am„+^ 1617141all Service Center,italcij#i,NC 276004617
11.Borehole diameter.8"/6" (in.) 24b.For lnieetlan.VSJ h ONLY:' In addition to sending the fomi to the address in
24a abavv- also subunit a copy° of this fetut within 30 days of completion of dull
lL,%,ellCo"S"Ctlonmdbod: 8"/6" Air H--er consituctionto the fbtlowilw
fix.ai am rotoy.coble.diym pnstt ck.)
DMslon of Water Remr*j ilnder[;rround injection Control Program,
FOR 14i+ATER SUPPLYWEMLS ONLY: 1636 Malt Se ite Center.Ral ft,N. C 27699-1636
13a,Yidd(gpm) method of test: 24c.For Water SoULIX&lWtuliin Wells:
Also submit one copy of this fohn within 30 ft'$of compWien of
13h.DhAnfeelion type Amount well con.0niction to the county h hh drpantwn of the county where
constmVed.
Farm Gilr-t Nonh Camlim DoT winwent of Emimm ins and 1lanwral Resuttnm-Division of R'atrrr Reww as Revised Ate 2013